Ann Thorac Surg 2005;79:2134-2136
© 2005 The Society of Thoracic Surgeons
Case report
Successful Treatment of a Posttraumatic Pulmonary Artery Pseudoaneurysm With Coil Embolization
Ioannis Dimarakis, MD,
James A.C. Thorpe, FRCS,
Kostas Papagiannopoulos, MD*
Thoracic Surgery Unit, Leeds General Infirmary, Leeds, United Kingdom
Accepted for publication December 10, 2003.
* Address reprint requests to Dr Papagiannopoulos, Leeds General Infirmary, Jubilee Bldg, Level D, Great George St, Leeds LS1 3EX, UK (E-mail: kpapagiannopoulos{at}yahoo.com).
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Abstract
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A 29-year-old man presented to the emergency department after having been stabbed in the posterior right hemithorax twice. He underwent thoracotomy for hemodynamic instability and continuous bleeding. His postoperative recovery was complicated by the incidental finding of a posttraumatic pseudoaneurysm of the pulmonary artery. We describe successful coil embolization of the aneurysmal sac avoiding any further surgical intervention.
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Introduction
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Traumatic pulmonary artery pseudoaneurysms are rare entities usually recognized by their complications. Few attempts have been described regarding nonoperative management with coil embolization in order to avoid surgery.
A 29-year-old man presented to casualty with penetrating chest trauma. He had sustained two stab wounds to the posterior hemithorax. Initial assessment and management was carried out in agreement with the advanced trauma life support protocol. Chest roentgenogram revealed the presence of a large hemothorax managed with an intercostal drain. The initial drainage was 1,100 mL. The patient remained hemodynamically stable and a computed tomographic chest scan showed a remaining hemothorax with no other obvious injuries.
After two hypotensive episodes in the radiology department requiring volume resuscitation and persistentchest drainage (700 mL), the patient was taken to the operating room. A right posterolateral thoracotomy was carried out. During exploration, the first stab wound was found to be coming through the sixth interspace. A sweating intercostal artery along with bleeding right upper lobe laceration was identified on the oblique fissure and hemostasis was secured with parenchymal suturing. The second wound tract was confined entirely in the superficial layers of the back with no intrapleural involvement.
Routine postoperative chest roentgenogram films revealed the gradual development of a well-circumscribed, noncalcified coin lesion within the right upper pulmonary field (Fig 1). A contrast enhanced computed tomographic scan of the thorax revealed a pulmonary artery pseudoaneurysm.
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Fig 1. Erect posteroanterior chest roentgenogram. Pseudoaneurysm shown as coin lesion in the right lung field; contrast enhanced computed tomographic scan (inset) confirms this.
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Pulmonary angiography showed that the pseudoaneurysm was arising from a subsegmental branch of the superior segmental artery of the right lower lobe next to the oblique fissure, although the laceration and knife entry point was at the right upper lobe. Successful embolization was carried out using four detachable embolization coils (Cook detachable embolization coil systems) (Fig 2). The patient was discharged shortly after in good clinical condition. He was reviewed 3 months postoperatively with no problems.
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Fig 2. Arterial phase of pulmonary arteriogram shows filling of the pulmonary artery pseudoaneurysm from a subsegmental branch of the superior segmental artery of the right lower lobe. (Inset) Embolization coils have been deployed within the sac. No further filling was seen.
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Comment
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Pseudoaneurysm and arteriovenous fistulas are two vascular complications of chest trauma [1]. Traumatic pulmonary artery pseudoaneurysms are a well described clinical entity, but they still remain rare with few cases reported. Also known as pulsating hematomas, false aneurysms are characterized by the sole presence of adventitia or even surrounding connective tissue, and they can occur after significant blunt or penetrating injury. Occasionally they may remain undetected and silent for many years [2]. The most common presentation is hemoptysis. Shortness of breath, chest pain, and hypoxia may also be present [3].
Complications include spontaneous rupture with life threatening hemorrhage prompting for early diagnosis and appropriate management. Other complications include infection and thrombus formation, which may lead to distal embolization and thrombosis [2, 3]. A traumatic pulmonary artery pseudoaneurysm has also been reported to simulate pulmonary embolism causing a differential diagnostic problem [4]. Endovascular treatment has been previously applied in lesions resulting from malignancy or iatrogenic causes such as right heart catheterization and chest tube insertion [5, 6]. Physiologic differences attributed to pressures approaching systemic values in left to right shunts, as seen in congenital cases, may deem endovascular treatment inadequate [7]. Coil deployment has been attempted in a posttraumatic lesion, but eventually the patient required lung resection for uncontrolled hemoptysis [2].
It is our belief that a high index of clinical suspicion should be maintained in such cases. Ill-defined opacities that persist on routine chest roentgenograms should be further evaluated. Contrast enhanced computed tomographic scanning followed by pulmonary angiography should be performed. If feasible, endovascular coil embolization avoids further surgery with resection of healthy lung segments. Otherwise precise localization of the lesion is mandatory for preoperative surgical planning. It is generally agreed that images such as Figure 3 are going to be more common in the future with the ongoing progress of interventional radiology.
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References
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- Symbas PN, Goldman M, Erbesfeld MH, Vlasis SE. Pulmonary arteriovenous fistula, pulmonary artery aneurysm, and other vascular changes of the lung from penetrating trauma Ann Surg 1980;191:336-340.[Medline]
- Savage SC, Zwischenberger JB, Ventura KC, Wittich GR. Hemoptysis secondary to pulmonary pseudoaneurysm 30 years after a gunshot wound Ann Thorac Surg 2001;71:1021-1023.[Abstract/Free Full Text]
- Donaldson B, Ngo-Nonga B. Amer Surgcase report and review of the literature. Traumatic pseudoaneurysm of the pulmonary artery 2002;68(5):414-416.
- Dillon WP, Taylor AT, Mineau DE, Datz FL. Traumatic pulmonary artery pseudoaneurysm simulating pulmonary embolism AJR Am J Roentgenol 1982;139:818-819.[Free Full Text]
- Oliver TB, Stevenson AJ, Gillespie IN, et al. Pulmonary artery pseudoaneurysm due to bronchial carcinoma Br J Radiol 1997;70:950-951.[Abstract]
- Benedetti E, Massad MG. Pulmonary artery pseudoaneurysm after tube thoracostomy Ann Thoracic Surg 1997;64:1478-1480.[Abstract/Free Full Text]
- Endovascular stent graft treatment of a pulmonary artery pseudoaneurysm Ann Thorac Surg 2001;71:727-729.[Abstract/Free Full Text]
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Abstract
Introduction
